Provider Demographics
NPI:1003968595
Name:MADISON RADIOLOGY ASSOCIATES, PA
Entity type:Organization
Organization Name:MADISON RADIOLOGY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-855-4000
Mailing Address - Street 1:PO BOX 4767
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-4767
Mailing Address - Country:US
Mailing Address - Phone:601-982-7878
Mailing Address - Fax:601-982-7909
Practice Address - Street 1:161 RIVER OAKS DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-5375
Practice Address - Country:US
Practice Address - Phone:601-855-4000
Practice Address - Fax:601-855-4330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08103711Medicaid
MS08103711Medicaid